Anxiety, Fear, and Depression

Cancer affects your emotional health

Most patients, families, and caregivers face some degree of depression, anxiety, and fear when cancer becomes part of their lives. These feelings are normal responses to this life-changing experience. In people with cancer, these feelings may be caused by many things, including changes in how they are able to fill family or work roles. A person with cancer might feel the loss of control over life events, and have to deal with changes in body image. They might feel grief at the losses and changes in their lives that cancer brings. They might fear death, suffering, pain, or all the unknown things that lie ahead. Family members and caregivers may have these feelings, too. They are often afraid of losing their loved one. They may also feel angry because someone they love has cancer, frustrated that they cant do enough, or stressed because they have to do more at home. Its important to remember that people with cancer, as well as their friends and family, can feel distress about these things at any time after a cancer diagnosis, even many years after the cancer is treated. And as the cancer situation changes, they all must cope with new stressors along with the old, and their feelings often change, too. For instance, people dealing with cancer thats spread and is making the person feel worse may have more emotional distress than those dealing with earlystage cancers. People who have physical symptoms such as pain, nausea, or extreme tiredness (fatigue) also seem more likely to have emotional distress. Most of the time, physical symptoms can be controlled with medicines but it could take more than one try to find the right drug or combination of drugs. This is one reason to stay in touch with the cancer care team, so that they can help with these kinds of symptoms before you feel overwhelmed. The information we talk about here can help families, friends, and caregivers know what feelings and behaviors they might expect from their loved one who has been diagnosed with cancer. It will also help you understand what isnt normal and when outside help is needed. And, it can help you recognize when you or others need outside help. Even though were talking about the person with cancer, all of these things can happen to caregivers, friends, and family members too. Anyone affected by cancer theirs or a loved ones might need help dealing with the emotions that result.

Depression and cancer

Its normal to grieve over the changes that cancer brings to a persons life. The future, which may have seemed so sure before, now becomes uncertain. Some dreams and plans may be lost forever. But if a person has been sad for a long time or is having trouble carrying out day-to-day activities, that person may have clinical depression. In fact, up to 1 in 4 people with cancer have clinical depression. Clinical depression causes great distress, impairs functioning, and might even make the person with cancer less able to follow their cancer treatment plan. The good news is that clinical depression can be treated. If someone you know has symptoms of clinical depression, encourage them to get help. There are many ways to treat clinical depression including medicines, counseling, or a combination of both. Treatments can reduce suffering and improve quality of life.

Symptoms of clinical depression

Ongoing sad, hopeless, or empty mood for most of the day Loss of interest or pleasure in almost all activities most of the time Major weight loss (when not dieting) or weight gain Being slowed down or restless and agitated almost every day, enough for others to notice Extreme tiredness (fatigue) or loss of energy Trouble sleeping with early waking, sleeping too much, or not being able to sleep Trouble focusing thoughts, remembering, or making decisions Feeling guilty, worthless, or helpless Frequent thoughts of death or suicide (not just fear of death), suicide plans or attempts Remember, some of these symptoms, such as weight changes, fatigue, or even forgetfulness can be caused by cancer and its treatment. But if 5 or more of these symptoms happen nearly every day for 2 weeks or more, or are severe enough to interfere with normal activities, it might be depression. If this is the case, encourage the person to be checked for clinical depression by a qualified health or mental health professional. If the person tries to hurt him- or herself, or has a plan to do so, get help right away.

What to do
Encourage the depressed person to continue treatment until symptoms improve, or to talk to the doctor about different treatment if theres no improvement after 2 or 3 weeks. Promote physical activity, especially mild exercise such as daily walks. Help make appointments for mental health treatment, if needed.

 Provide transportation for treatment, if needed. Engage the person in conversation and activities they enjoy. Remember that its OK to feel sad and grieve over the losses that cancer has brought to their lives, and to yours. Realize that being pessimistic and thinking everything is hopeless are symptoms of depression and should get better with treatment. Reassure the person that with time and treatment, he or she will start to feel better and although changes to the treatment plan are sometimes needed, its important to be patient. If you suspect you may be depressed, see a doctor. Make time to get the help and support you need.

Do not
Keep feelings inside. Force someone to talk when they are not ready. Blame yourself or another person for feeling depressed Tell a person to cheer up if they seem depressed. Try to reason with a person whose depression appears severe. Instead, talk with the doctor about medicines and other kinds of help.

Anxiety, fear, and cancer

At many different times during their treatment and recovery, people with cancer may be fearful and anxious. For most people with cancer, finding out that they have cancer or that the cancer came back causes the most anxiety and fear. Fear of treatment, doctor visits, and tests might also cause apprehension (the feeling that something bad is going to happen). Its normal to feel afraid when youre sick. People may be afraid of uncontrolled pain, dying, or what happens after death, including what might happen to loved ones. And, again, these same feelings may be experienced by family members and friends. Here are some signs and symptoms of fear and anxiety.

Symptoms of anxiety and fear

Anxious facial expression Uncontrolled worry Trouble solving problems and focusing thoughts Muscle tension (the person may also look tense or tight) Trembling or shaking

 Restlessness, may feel keyed up or on edge Dry mouth Irritability or angry outbursts (grouchy or short-tempered) If a person has these symptoms most of the day, nearly every day, and they are interfering with his or her life, a mental health evaluation could helpful. Keep in mind that sometimes, despite having all the symptoms, a person may deny having these feelings. But if they are willing to admit that they feel distressed or uncomfortable, therapy can often help.

What to do
Encourage, but do not force, each other to talk. Share feelings and fears that you or the anxious person may be having. Listen carefully to each others feelings. Offer support, but dont deny or discount feelings. Remember that its OK to feel sad and frustrated. Get help through counseling and/or support groups. Use meditation, prayer, or other types of spiritual support if it helps. Try deep breathing and relaxation exercises. Close your eyes, breathe deeply, focus on each body part and relax it, start with your toes and work up to your head. When relaxed try to think of a pleasant place such as a beach in the morning or a sunny field on a spring day. Talk with a doctor about using anti-anxiety or anti-depressant medicines.

Do not
Keep feelings inside. Force someone to talk if theyre not ready to. Blame yourself or another person for feeling fearful or anxious. Try to reason with a person whose fears and anxieties are severe; talk with the doctor about medicines and other kinds of help.

Panic attacks and cancer

Panic attacks can be an alarming symptom of anxiety. Panic attacks happen very suddenly and often reach their worst within about 10 minutes. The person may seem fine between attacks, but is usually very afraid that they will happen again.

Symptoms of a panic attack

Shortness of breath or a feeling of being smothered*

 Racing heart* Feeling dizzy, unsteady, lightheaded, or faint* Chest pain or discomfort* Feeling as if theyre choking* Trembling or shaking Sweating Fear of losing control or going crazy An urge to escape Numbness or tingling sensations Feeling unreal or detached from themselves Chills (shaking or shivering) or hot flashes (may involve sweating or facial reddening) *If a person is having any of the first 5 symptoms (marked with asterisks), it can mean an urgent or life-threatening condition. Call 911 or the doctor right away if someone unexpectedly has any of these. These symptoms can be signs of other, more serious problems such as shock, heart attack, blood chemistry imbalance, collapsed lung, allergic reaction, or others. Its not safe to assume that they are panic-related until diagnosed by a doctor. If the person has had panic attacks in the past, and it happens again exactly like it did before, they can often recognize it as a panic attack. If the person recovers completely within a few minutes and has no more symptoms, its more likely to have been a panic attack. If panic attacks are diagnosed, brief therapy and medicines have been shown to be helpful.

What to do
Check with the doctor to be sure that the symptoms are caused by panic and not another medical problem. Stay calm and speak softly during a panic attack. Sit with the person during panic attacks until he or she is feeling better. Call for help if needed. After the panic attack is over, encourage the person to get treatment for the panic attacks. Provide transportation to treatment if needed. The person may be afraid that a panic attack will happen while driving. The ideas listed under What to do in the section Anxiety and Fear may also be helpful.

Do not
Minimize or make light of the persons terror or fear. Judge the person for feeling scared and acting strangely. Try to talk the person out of their fear or other feelings. Hesitate to call the doctor if you have questions about whats happening.

What if the person with cancer acts as if nothing is wrong?

Be aware that your loved one may put up a false front, or put on a happy face, even if he or she doesnt really feel that way. This may be their way of trying to protect the people they love, and possibly themselves, from painful feelings. And some people believe that a person with cancer can improve their outcome by being cheerful and happy all the time. Studies of coping styles and survival or recurrence show that being cheerful has little to no effect on cancer. But some people with cancer feel guilty for being sad or fearful, and may try to act happy and be positive even when its painful to them. (See our document called Attitudes and Cancer for more on this.) If you think that this is happening, gently tell the person that you are willing to listen to their feelings, no matter what they are. The message may be something like, I care about you, and Im here for you whether you are happy, afraid, angry, or sad.

Support from loved ones and the cancer team can help
It may help to know that patients with more social support tend to feel less anxious and depressed and report a better quality of life. People with cancer find it encouraging to have others who listen and help with the practical aspects of dealing with cancer. Asking family members and loved ones for this kind of support may help reduce the patients distress and the distress of those who care about him or her. Being able to talk with the cancer care team about medical fears, concerns about pain, and other issues may also help the patient feel more comfortable. Someone who is close to the patient might offer to go with (or take) them to the doctor. Being with them may have a calming effect, and that person might be able to help the patient remember symptoms or problems that need to be addressed. The doctor and cancer care team can answer questions and talk about any concerns you have. They can also refer the patient to a mental health professional if needed. Depression, anxiety, and other emotional problems can nearly always be helped with a combination of medicines, support groups, or psychotherapy. But first, a person must recognize that they need help dealing with their emotions and their responses to the major changes that cancer brings to their lives. In the confusion and stress that come after a diagnosis of cancer, the emotional problems of both people with cancer and those around them can often become fairly serious before theyre recognized.

When to call the doctor

Going through a wide range of emotions is a normal part of coping with cancer. But some things should not be ignored. If the patient or someone close to them has any of these problems, please call the doctor right away: Has thoughts or plans of suicide (or of hurting himself or herself) Is unable to eat or sleep Lacks interest in usual activities for many days Is unable to find pleasure in things theyve enjoyed in the past Has emotions that interfere with daily activities and last more than a few days Is confused Has trouble breathing Is sweating more than usual Is very restless Has new or unusual symptoms that cause concern Theres no doubt that cancer changes peoples lives. The emotional stress it causes can be overwhelming, but no one has to manage it alone. The patients health care team may seem focused on his or her physical health, but they care about their patients emotional health, too. Keep them involved in and aware of what the patient is feeling and doing. Learn about and use the resources available. Coping with cancer is stressful, but no one has to do it alone.

To learn more
More information from your American Cancer Society
Here is more information you might find helpful. You also can order free copies of our documents from our toll-free number, 1-800-227-2345, or read them on our website, www.cancer.org.

Living with Cancer

Distress in People With Cancer After Diagnosis: A Guide for Patients and Families (also in Spanish) Coping With Cancer in Everyday Life (also in Spanish) Talking With Friends and Relatives About Your Cancer (also in Spanish) Attitudes and Cancer Living With Uncertainty: The Fear of Cancer Recurrence Chemo Brain

For caregivers and friends

When Someone You Know Has Cancer (also in Spanish) Listen With Your Heart (also in Spanish) Caring for the Patient With Cancer at Home: A Guide for Patients and Families (also in Spanish) What It Takes To Be a Caregiver What You Need to Know as a Cancer Caregiver

If cancer treatment stops working

When Your Cancer Comes Back: Cancer Recurrence Advanced Cancer

National organizations and websites*

Along with the American Cancer Society, other sources of information and support include Substance Abuse and Mental Health Service Administration (SAMHSA) Website: www.samhsa.gov Toll-free number: 1-877-SAMHSA-7 (1-877-726-4727) (also for Spanish) TTY: 1-800-487-4889 International telephone number: 240-221-4017 Free information on mental health and substance abuse, as well as referrals to treatment Suicide Prevention Hotline Toll-free number: 1-800-273-TALK (1-800-273-8255) TTY: 1-800-799-4889 Website: www.suicidepreventionlifeline.org Free, confidential prevention counseling and information for those who may be thinking of suicide or hurting themselves; available anytime 24/7. You will hear hold music while you are being routed to a nearby crisis center American Psychosocial Oncology Society (APOS) Toll-free number: 1-866-APOS-4-HELP (1-866-276-7443) you may need to leave a message, but calls are normally returned within 48 hours Website: www.apos-society.org For a free, confidential referral to a local mental health professional or cancer support group; also has recommended books and videos CancerCare Toll-free number: 1-800-813-HOPE (1-800-813-4673) Website: www.cancercare.org Online, choose our services or support groups to learn about telephone or Internet support available to anyone affected by cancer

National Institute of Mental Health (NIMH) NIMH Public Health Inquiries Toll-free number: 1-866-615-6464 TTY: 1-866-415-8051 Website: www.nimh.nih.gov For information on symptoms, diagnosis, and treatment of mental disorders see Health and Education for mental health info if you visit their website
*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association, Arlington, VA. 2013. Jacobsen PB, Jim HS. Psychosocial Interventions for Anxiety and Depression in Adult Cancer Patients. Achievements and Challenges. CA Cancer J Clin. 2008;58:214-230. National Institute of Mental Health. Mental Health Topics. Accessed at www.nimh.nih.gov/health/topics/index.shtml on September 20, 2013. Parker PA, Baile WF, de Moor C, Cohen L. Psychosocial and demographic predictors of quality of life in a large sample of cancer patients. Psychooncology. 2003;12:183-193. Petticrew M, Bell R, Hunter D. Influence of psychological coping on survival and recurrence in people with cancer: Systematic review. BMJ. 2002;325:1066. Pirl WF. Evidence Report on the Occurrence, Assessment, and Treatment of Depression in Cancer Patients. JNCI Monographs. 2004(32):32-39. Accessed at http://jncimono.oxfordjournals.org/cgi/content/abstract/2004/32/32 on September 20, 2013. Rodin G, Lloyd N, Katz M, et al. The treatment of depression in cancer patients: a systematic review. Support Care Cancer. 2007;15(2):123-136. White CA, Macleod U. ABCs of psychological medicine: Cancer. BMJ. 2002;325:377-380.

Last Medical Review: 9/20/2013 Last Revised: 9/20/2013 2013 Copyright American Cancer Society